Pushing the Envelope

Listen as Karl Stonecipher, MD, speaks with host Gary Wörtz, MD, about the bold individuals in the field of ophthalmology who helped pave a pathway forward for others, and why it's important to be open to new ideas. Dr. Stonecipher is a clinical associate professor at the University of North Carolina, and he has a private practice where he specializes in cataract and refractive surgery.

Gary Wörtz: Open, outspoken. It's Ophthalmology off the Grid—an honest look at controversial topics in the field. I'm Gary Wörtz.

Throughout history, plenty of individuals have found themselves ostracized for having radical ideas, only to later be embraced for those same ideas. It can be uncomfortable to upset the status quo, but testing limits in a responsible manner is one way we can make our profession even better.

Dr. Karl Stonecipher believes it's important to be supportive of new ideas because those who are willing to go against the grain a little bit are the ones who will ultimately help this profession advance.

Karl's a clinical associate professor of ophthalmology at the University of North Carolina, and he has a private practice where he specializes in cataract and refractive surgery. He spoke to me about the importance of being open to change and about the bold individuals in the field of Ophthalmology who help pave a pathway forward for the rest of us. Coming up, on Off the Grid.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

Gary Wörtz, MD: Welcome back to another very special edition of Ophthalmology off the Grid. This is Dr. Gary Wörtz, and I have the distinct pleasure of talking to all of our great friend, Dr. Karl Stonecipher. Karl is a giant in the field who needs no introduction. He is a clinical associate professor of ophthalmology at University of North Carolina, and he is in private practice in Greensboro, North Carolina, where he specializes in cataract and refractive surgery.

Karl has been just very active in all sorts of anterior segment surgery, and as Karl and I have gotten to know each other through the years, and even more so just prior to this conversation, I realize there's sort of a “Paul Harvey, The Rest of the Story,” that Karl can probably tell better than I can with regard to the real beginnings and pioneering of refractive surgery. And so, Karl, with that big introduction, welcome to the show. Tell us a little bit about where and how you got started, and fill in the details where they need to be filled in.

Karl Stonecipher, MD: Well, first, I'm honored to have you as a friend, and I'm honored to be on the podcast, because you've got some really great people that have been on this podcast. Those of you that haven't listened to previous podcasts, go back. There's some really great stories along the way.

The one thing that I want to kind of dovetail in on, Gary, is one that I was part of, and that was your recent podcast with Marguerite. So, I will tell my story of how I entered into the world of ophthalmology blind, so to speak. I was just like Marguerite. I lived a life of myopia that was undiagnosed. Funny anecdotal story, when I turned about 11, my dad, I don't know if you know, signed for the Yankees in 1951. They won the NCA in baseball, which is kind of poignant now, because the Cubs World Series is on. So, everybody would think, okay, I have this guy's great genes.

There was a Big Eight All-Conference football player that my dad knew well from Oklahoma, and he was my coach as a little league football player. So anyway, I'm out there playing football, thinking I'm a great football player, and later that night my coach goes to my father and says, "I hate to tell you this, Stoney, but your son is really bad at football, and he really sucks." I didn't know about the conversation. My dad comes home, tells my mother. Well, my mother is totally devastated. She's not about to have some child that's not athletically inclined, with the genes in the pool that we had.

So, she took me to this guy named Stan Muenzler, and there by the grace of God go I, Stan Muenzler is the same guy who gave me my first pair of glasses, gave me my first pair of contact lenses, wrote my medical school admissions letter, and wrote my residency letter.

Gary: Wow.

Karl: Where that all dovetails in is, I'm a medical student at the University of Oklahoma, and my uncle was a famous cardiologist in Houston, Texas, who worked with the Denton Cooley and all the great heart surgeons. So, as a youngster I got to go watch all these fantastic people do heart transplants, and these bypasses, and all this crazy stuff. So, all along I thought, well, I didn't want to be an internist, I wanted to be a surgeon, and I was going to be a cardiothoracic surgeon.

Fast forward again, I'm now in medical school in the third year, and I'd done a lot of research in college, and had a paper published, and that sort of thing. And so, I thought, "Well, great, I'm going to be a thoracic surgeon, I better go in and talk to the head of thoracic surgery." I put my grades out, and he said, "Karl, you're going to be a great surgeon, but I don't think you're going to be a thoracic surgeon because I don't think you have the personality."

I didn't know if he was being nice or if he was being mean, but I thought, "Okay, my life's over. I can't be a thoracic surgeon." And one of my friends suggested that I go see this guy named Dr. Jim Rowsey, who was looking for a research coordinator. It was a tough time. He'd just lost his wife, and so he really kind of needed a shoulder, and I happened to be that.

He gave me this project, which was counting these little rings and all these little dots. I thought, "Well, that's kind of cool." That's where we kind of found computer typography, and Jim was one of the first PRK study individuals, working with George Waring. So as a senior, I was kind of thinking, maybe this ophthalmology thing isn't bad. You get to sit down, like Marguerite was saying, when you operate. It's not so hard on your legs and your back. I kind of like it, because you're kind of the family practice guy of the eyes, so you get to do a little bit of everything, seeing kids, and adults, and older patients.

This is something I can do, but I really kind of thought, "Well, shoot, maybe I ought to decide if I really want to do this." So, as a senior, I went and did an externship at LSU in New Orleans, because the same guy that did my glasses, same guy that did my contact lenses, set me up with this guy called Henry Van Dyke, a neuro-ophthalmologist at LSU. He said, "You need to go there. It's a great spot. You'll learn everything. New Orleans is a great spot."

I went down to New Orleans back in 1986, and Hank knew that I was interested in refractive surgery, and that's when I got to meet Herb Kaufman and this lady named Marguerite McDonald. I was just some lowly medical student, but she really took me under her wing and said nice things to me, and said, "Come by my practice or my office anytime." I thought, "Well, gosh, this is a place that I need to be."

Well, that didn't work out because they said, "Well, we're kind of full next year, but we would love to have you the following year." And, I just did happen to get into Tulane, and so I thought, "Well, shoot, Tulane's right here. They share a lot of different stuff."

Back in the days of 1987-1990, when we were coming to fruition with things like epikeratophakia and keratomileusis, and we were working with all these different types of things we call excimer lasers, and we thought, "Well, wow, this is pretty cool."

I was at Tulane, working with this guy named Steve Brint, who happened to be this brainiac cataract surgeon, and I also got to work with this other great cataract surgeon at the time, Bruce Wallace. They kind of took me under their wing, and I can still remember I picked up the engineer's persona. So, not only did I get to work with Steve Brint, but I also got to go and work at the Visx platform with Marguerite at the time when Marguerite performed the first PRK, as she said, serendipitously, because the lady was functionally blind, and comes back one day and says, "Oh, by the way, I can see," and Marguerite's like, "No, you're really not supposed to see." Everybody was a little bit stifled by that, and so Herb Kaufman says, "We're going to go to the FDA. We're going to make lemonade out of lemons," and the rest is history.

There were a lot of back-and-forth problems in terms of scathing comments and literature, and like you said in the podcast, it's a thing of the past and nobody remembers the negativity. But, what I'd like to do in this podcast, with that as kind of a backdrop is, how do we decide that Marguerite was a pioneer, and at what level did she go from being a pioneer to a buccaneer?

I read this awesome book called The Butchering Art, by Lindsey Fitzharris, recently. I strongly encourage anybody that's in medicine or wants to be in medicine read it. It's about medicine in the 1800s before anesthesia and antimicrobials.

Gary: Wow.

Karl: You’ve got to imagine that there is not a whole lot that can be done at this particular time, because if you had surgery, you died from disease, and sometimes if you had surgery, you died from the surgery. So, we're here at this point in the early 1800s, and this famous surgeon who thinks he's the best in the world performs an amputation in like under 3-4 minutes, which is just absolutely incredible, during which he removes the leg, he sews the vessels, he sews the stump, all in under 4 minutes, which is like running a 4-minute mile, his time.

Gary: Right.

Karl: But, the sad part about it, the procedure had a 300% mortality. The patient died from disease. The medical student watching the process got clipped with the knives; he died from disease. Last but not least, the technician who was working on the leg or holding the leg got clipped with the knife, and he died from an infection as well. So here we have this great surgery, but a 300% mortality.

So, everybody still thinks this guy is great, and this guy named Lister is really an idiot, and he doesn't really know what he's talking about. Why would somebody want to use a microscope? So, at what point do we get to the level where this other guy is kind of the one that's not the great surgeon, and Lister is the guy that's making groundbreaking molds in terms of…

Gary: Advancements.

Karl: Yeah. And we go back, I mean, it can go across different cultures. We look at Einstein. I don't know if you remember, Einstein's story was, this guy's this genius, but everybody thinks, "Okay, I don't really believe this." And there's this guy named Eddington in England that says, "Well, that makes sense to me." So, he goes down and looks at this thing we call an eclipse and proves Einstein's right, and basically, Eddington isn't really remembered and Einstein is remembered forever.

Gary: Right.

Karl: So we stand on these shoulders of giants, and for me, they're people like Marguerite McDonald, Steve Klyce, and Jim Rowsey, and the guy that gave me my first job, Del Caldwell, who kind of said, "Okay, you sound like you know what you're doing, so if you want to go do some research, you can." All these guys that we work with every day, you and I don't realize how much they've done for us, whether it's George Waring or Dick Lindstrom—a lot of these guys paved a lot of pathways.

Karl: In the old days, when we look at radial keratotomy, there's this guy, Lans, in the 1800s who decides he's going to make incisions in the cornea and looks at that. Then there's this guy, Sato, that was familiar with the work, but unfortunately, he works from the…

Gary: Yeah, the endothelial side.

Karl: He didn't really know there were endothelial cells, and he got the highest honor in Japan, only to find out 15 years later all his patients went blind from their endothelial dystrophy that he had created.

Gary: Right.

Karl: And even though we move through the process of Fyodorov, and all these other different people, that a lot of people thought all those guys and gals were basically buccaneers, as I've labeled them, and then at some point we look back at Charlie Kelman, who was ostracized by his entire community. He was thrown out of all these different societies. And finally, one day somebody says, "Oh no, that guy's a pioneer." Ridley, same thing.

Gary: Right.

Karl: And here is a guy that really invented the way we do modern cataract surgery, maybe not the same technology, but definitely the same ideas and ideals.

So, with that as a backdrop, I think in this present day and age, what I'd like to discuss with you is, where are we going with refractive surgery, and where are we going to end up on the other side? I think that the cornea's a great spot, but lately inside the eye has been a great spot.

We've seen a lot of advances in technology with presbyopia, and we really want to make it to where people see what they saw through glasses or contact lenses. We're at the 20/15 or better level in terms of outcomes with LASIK, but when we get these patients with what we've termed the dysfunctional lens syndrome, at what point can we say to that patient that this cataract surgery, what we're going to call refractive lensectomy, is a good thing?

In 1991, I still remember, I ran into this famous guy named Ioannis Pallikaris. I walked up to him at ARVO and said, "You guys are doing this really cool stuff. I really don't believe in hyperopic refractive surgery of the day, and I don't think making incisions is the right thing, and I don't think cutting the cornea really deep and producing this, what we call, clinically controlled ectasia or hyperopic A-OK is the right way to go." And he said, "Of course. The simple thing to do is work inside the eye." And it was just like, bing, a light bulb goes off in my head, but I go back with that thought and everybody says to me, "Oh my gosh, that's the craziest thing I've ever heard in my entire life."

Now, fast forward 27 years later, and it's more of a common statement, and we're even thinking about doing it bilaterally. So, in the great state of North Carolina, we can't do that, but in the great state of California, you can do bilateral surgery. And I still remember when I started doing bilateral LASIK back in '94, '95, in the CRX LASIK study, and people were like, "You're really operating on both eyes? You're an idiot for doing that in the first place, because these are normal eyes and sighted eyes." So, where do we find out that what we think is right, is best for our patients?

I go back to my cardiologist uncle, and his comment was very simple: If you would do this to a family member, your mom, your dad, your brother, your sister, you're probably going to be OK in the big picture. And if that's what you believe in, and that's what you're good at, I think that you're going to find that whatever that it, it will pan out in the end, or somebody will look at you and say, "Gary, Karl, I know this is a great idea, and I know you got some great research on it, but I'm going to pat you on the back and say, 'Let's move forward to something different.'"

If we look at presbyopia at the present time, we know monovision is great. Alan Kaufman and I produced some good research on that and presented that data in terms of where people should be, maybe, after cataract surgery or refractive lensectomy, before we had really good lenses.

And, again, these people that I talk about, like Bruce Wallace and Dick Lindstrom and Steve Brint, I watched them suffer through the 3M multifocal lens and some of these other options that Jim Gills and some of these other great surgeons tried for us before. Then, we finally get to where we are today, where we're actually producing lenses that maybe don't accommodate to the appropriate level, but the patient can accommodate to the technology, and it works extremely well for them.

Gary: Right.

Karl: My favorite anecdotal story was, so I'm on with this new thought process about Ioannis Pallikaris, and his buddy saying, "You ought to go home and try refractive lensectomies on all your hyperopic patients." The first guy, just lucky as can be, just like Mrs. Cassidy with Marguerite, says to me, "Hey, I'm here." And he was a +9 with 3.5 diopters of astigmatism. So, I said, "Look, I got good news and I got bad news." He said, "Okay, I've been there before. The good news is technology is going to come. The bad news is it isn't here yet.” I said, "Well, no, no, sir, wait a second. Let me tell you, the good news is the technology is here. The bad news is, it's very expensive." I didn't know the guy had just sold his company for about $120 million.

Gary: So that's not a problem. The money is not a problem at this point.

Karl: Here's my Mrs. Cassidy, and God rest his soul, he just died last year and probably referred over 60 or 70 patients to me, which, he paid for their surgery, and there by the grace of God go I, I will always say that, everything turned out perfectly. I did astigmatic incisions with a diamond blade. I did the small incision, no-stitch cataract surgery at the time I could do. And for the rest of his life, this guy, it was a new world for him.

And people don't realize, until you hear a story like Marguerite's, how devastating it is to be that nearsighted or farsighted, and how confined your world could be in terms of that. So, I think that with technology, as we're going through today, and, I mean, you get to see it and hear it every day, because you're grabbing the brainiacs of the world of glaucoma or retina, and they're coming up with all these phenomenal ideas.

But sometimes it takes a few, a village let's say, or a few people, to look at Gary and say, "Hey, Gary, that's a great idea. Why don't you go see if you can do it?" Collect your data, and if the data is good, then it's going to stand on its own. And the person that taught me better than anybody is Dan Durrie, in terms of collecting data, and Dan's just like a phenomenal data collector.

I can still remember early on he'd look at me, and he'd go, "Okay, Karl, that's a great study, but it really doesn't count.” I was like, "Well, you know, I followed the rules. I did the data review board thing." And he goes, "Yeah, but until you do one eye this way and one eye that way, it probably doesn't count." He said, "You know with me, I'm kind of the contralateral eye guy."

I was like, "Okay, well, you can't always do that." And he said, "I know, but when you can, try, as long as you don't think you're doing something too avant-garde." So, we look at these people, whether they're Spencer Thornton or some of these guys like [Sinskey] and [Kensaku]. I happened to have the opportunity to be in the IIIC Club. So, I have a lot of these major brains that I get to eat dinner with twice a year.

And a lot of people, it's like going and sitting with your grandfather and hearing these great stories in ophthalmology. And every single one of these people will tell the same story: "I was ostracized by my peers. Many people looked at me and said, 'This is not the right thing to do. You're going down the wrong rabbit hole.'" I think that we look now at some of the technologies that have gone by the wayside that, at the time, we thought they were the best thing in the world.

I did probably over 20,000 radial keratotomies, and I was very proud, and I'm still very proud of that procedure, but those patients are doing what now? They're walking through the door with their cataracts. And so we got to listen to the Jack Holladays, and the Warren Hills, and the Doug Kochs of the world, and try and figure out how we best fit with our new technology and get these guys back whole, because I think that, yeah, we make mistakes all along. I always say experience means you've done it wrong before.

Gary: Right.

Karl: We all have done it, altruistically thinking wrong, and like Marguerite used the term over and over again, serendipitously sometimes we walk through the raindrops. But I think, the one line that I always remember Jim Rowsey used to always say to me, "If I give it to you, you can't steal it." So, when we're trying to exchange ideas today, the problem we have is intellectual property. And somebody is always saying, "I've got to make a buck off this," or, "I've invested my life savings in this." And I understand that, but at the same time, if somebody's barking up the wrong tree, I would hope that we as individuals would be able to walk to Karl or Gary and say, "I've been down that road before, and it's not going to lead you anywhere. But if you think about it this way, and you come over to my house, and let me show you how I'm doing it, I think that's great."

And I encourage all of the young residents and surgeons, I've got two coming to see me tomorrow, they’ll look over my shoulder, and they'll say, "Wow, you do it that way, don't you?" And I'm like, "Well, I really didn't know I did it this way. I really didn't learn it on my own. I watched a lot of people, and I watched a lot of videos, and I talked to a lot of people, and I stood there waiting patiently at the end of the lecture, and would ask my questions, which most of the time were probably stupid to the person I was asking, but I always would do it politely."

And I think that most of these individuals you'll see will look at you and say, "Maybe I'm busy right now. I'm running off to a talk, or I've got to get dinner with my wife or something, but, hey, here's my card. Call me, or email me." Follow that stuff up, because I think that's how you and I, our DNA is made that way.

Gary: Right.

Karl: I know you're a friend of mine, but I think that not everybody's that way in terms of this big process. And the other thing I tell the residents, you have one moment in time to do everything, and that's during your residency. So, when they call you on call and say, "I got an open globe," or, "I got a lid laceration," or, "I got some really messed up eye," you look at that not as a, "Oh gosh, I get up at 2 o’clock in the morning, I got to go fix it." You look at that as an opportunity to try and make somebody see, which maybe or maybe not you can. But, I was lucky to train at probably one of the war zones of the world, which was Charity Hospital in New Orleans, and we saw just amazing stuff.

But out of that came what? Phenomenal advances. And I will tell you anyone from World War I, which I don't know, but II, and Korea, and Vietnam, I definitely had spoken to many of those surgeons, and they said they learned more on the battlefield many times than they did back home in the university.

Gary: Right. So, let me unpack a couple of things, because you brought up a multitude of just amazing points. It is interesting as we, in the year 2018, look back on the history of ophthalmology, the most phenomenal advancements have always been fought tooth and nail by the status quo. And one of the questions I would have, because you've seen this I guess maybe through a couple iterations of change, one question I would have for you is, do you think that we as a society of ophthalmologists are getting better at accepting game-changers or disruptive change, or do you feel like as a society we still suffer from the don't-move-my-cheese-type of issues that have plagued us in the past?

Karl: I think you have societies and groups that are now binding themselves together. I think CEDARS/ASPENS is a group that is out there trying to say, "Okay, look, we have some newer opportunities and ideas. Let's see how we can change that world." And I think there will always be the more tried and true methodology, the typical surgeon mentality that says, "No. This is how I was trained, and I'm going to stick with what I'm trained because it's worked great for me."

And I think that's fine. I just think that the real game changers are the people that stick their necks out. And I’ll tell you another anecdotal story. I just happened to be speaking for the West Virginia ophthalmology society, and I'm talking on how to make one eye at a time see better in terms of 20/15 or better vision. I got this guy, Dean Eliott, that gets up and starts talking about how they're creating this biological gooey that they're sticking under the retina and curing Leber's blindness in a kid that's like 8 years old who couldn't ride his bike anymore. And now he can ride his bike again.

Now, when you look at that, and we were talking about LASIK or laser floater removal, which is pretty controversial now, and you sit there and you go, "Okay, Dr. Eliott. Dean, tell us how much does it cost to cure blindness?" And he's like, "$500,000 to $700,000 US dollars per dose." So, we got to look at the cost of medicine too. But, boy, they 3D printed a cornea the other day. So, in length term, they put in red, green, and blue ink, endothelium, epithelium and …

Gary: And stroma.

Karl: And created a cornea. Now, we're a bit off before you're going to stick that in an eye probably. But, these guys that are out there doing, at all costs, and granted they're going to need reimbursement for those investments, and I still never will FDA bash. I just say that we'd like to see these processes move a little bit quicker. But, I understand the stringent [regulations] there too. But, I think you're always going to have somebody standing in the way, which is the little red engine that couldn't. I think that somebody's always going to say to you it's—I highly admire him. Steve Charles was one of my heroes. He's always been one of my heroes. I've always thought he was one of the smartest brains in the world.

Gary: Agreed.

Karl: But, I do laser floater removal, and he thinks that is a pretty bad thing to do in this normal vitreous, and this normal process. But, I work with six great retina surgeons. Most of them send patients to me and say, "Hey, Karl, why don't you try this laser floater removal thing first." And if it doesn't work, they can always have the opportunity of having what?

Gary: Yeah, vitrectomy.

Karl: A vitrectomy. But they’ll look at me, and they'll say, "Karl, if this is a phakic person, I'm going to create a cataract. So not only am I going to get rid of their floater, I'm going to give them cataract, and they're going to come to you to get their cataract surgery." So, I think we all have to see the forest for the trees. And I've tried to have that conversation with Dr. Charles about laser floater removal, but that's kind of one of those things that Marguerite ran into at the time that basically said, "You're off the rails. You're not thinking right. Why would you want to operate on a normal eye that you could put -8.00 lenses on?"

But, I tell you the best thing that we did at Tulane, it was the first week or two when we were doing our optics lectures, the first month at Tulane, I don't know if you did this …

Gary: Yeah.

Karl: We all had basic science. And so, the professors came in and taught us basic science. And the best thing I saw was, one of the professors made us wear -20.00 contact lenses, and put on +20.00 lenses. Then he had this all made up. And then we had like just the opposite, +10.00 lenses on, and wear -10.00 glasses. And so, it was absolutely learning jack-in-the-box phenomenon, and all this pin cushion, and …

Gary: Right.

Karl: … minification and magnification for real. The other one that I'll never forget is, they tape our eyes shut, completely shut. So, one day you are my partner, and the next day I had another partner. And we all went around either blind or sighted. So, you and I would be partners, so you wouldn't run me into walls and stuff and think that was funny because you knew I was doing the same thing to you the next day.

But, boy, it was amazing how you were treated being blind and how your other senses came to fruition. So, I think with that, we got to kind of take away some of our short-sightedness and start thinking outside the box. If somebody comes up with a program, let's see where we're at. And one of the other programs that I always recommend is at the American Academy of Ophthalmology. They always do this “vision through the eye of the artist,” and [the head at Stanford] always gives these great lectures about all these famous painters who at the beginning they thought they were kind of crazy, like Picasso or Matisse, and all these other different people. And now we look at them and say, "Oh my gosh, wouldn't I love to have one of those."

Gary: Right. Absolutely. I want to also talk about, I think, one of the biggest focal points that you brought up is really lens-based refractive surgery. I want to give you a scenario of a patient that I took care of. Actually, I've had two of these patients in the past couple of months. The patient came in to me in her mid 30s, so not even presbyopic yet. She was a +7.50 -6.50 in the right eye and a +5.00 -5.75 in the left eye, correctable to 20/30, 20/25, a little bit a refractive amblyopia.

And this is a patient who is highly educated. She is, I believe, a nurse, but is no longer able to drive because she has become contact lens–intolerant, and her glasses, with the optical effects of her glasses, she does not feel comfortable driving. She's single. She's having a hard time socially, just feeling like she's being left out of a lot of things in life.

And she came to me after seeing a number of different ophthalmologists and optometrists, specialty contact lens fitting, etc., etc. Basically, she was at the end of her rope, and she just asked me if technology had advanced and if anything could be done at this point. I have to say, I'm really thankful to industry for having the opportunity to have multifocal and extended depth of focus lenses that are also in toric form.

And I won't mention the brand of the lens I use because I think that really all of these categories of lenses can be very helpful. But, I went ahead, and after a long conversation with her and her family, I said, "We can't do LASIK on you, but what we can do is we can do laser refractive lens-based surgery, where we're going to put this lens that has a range of vision with correction of astigmatism." And because those lenses don't go up that high, I had to add two 60-degree arcs on top of the toric lens. I did that in both eyes. And this patient is actually uncorrected 20/25 in both eyes. And when she came back for her postop exam, she and her mother were both in tears because it was the best she had ever seen in her life, and her mother was carrying this guilt around for so many years about having this child that she just could not help.

For me, we all have these patients that, on the negative side, perhaps we remember, because they were 20/20 and ungrateful or something of that sort. But, it's these really special patients that I carry, I try to carry with me, where I think, "We won, and thanks to the confluence of technology, both the laser side, and lens side, and being a little bit bold, we were able to help that patient.” That meant so much to me, to see how it really impacted her quality of life. That's just one example in my personal life where doing exactly what you said made such a huge difference in one patient's life. What are your thoughts about that?

Karl: I kind of laugh the way you present that. I don't know if you ever remember the movie The Big Chill.

Gary: Yeah.

Karl: The Big Chill said, "Rationalizations are better than sex. When did you go a whole week without a good rationalization?" So, you had to rationalize to yourself, "Okay, how can I make it okay for me to operate on this person who is, (A) miserable and (B) functionally blind in our world, not her world—our world?" So, you have to come up with a good rationalization to yourself. I'm hoping there's going to be a day where we don't have to rationalize that. We can say to the kid I just had, I was laughing here quietly because I've had a -24.00, that was his cylinder, come in from his parents, exact same story, said this kid can't wear contact lenses. "He lives in our basement. He has no job. He has no girlfriend. He does nothing but play video games all day, and he essentially has no driver's license, no life."

I sent him off to ... I usually will pick a few retina surgeons in the community, try and tell them what I'm trying to do, and I think that's very important. And there's always going to be guys that say, "No, no, no, I don't want to do that. I don't want to let you be a part of that," or whatever. And I'm okay with that, and I said, "Okay, but I want to try and give this person the best shot.” So, I'll have him go see my retina colleague, and if my retina colleague says they got a retinal hole or tear, they'll fix it, and work through it. C.P. Wilkinson, somebody I trained under, who probably knows a lot of the data on when and where to delay for these people, and when and where not to do surgery on them. And that was back in the late 80s and early 90s.

Fast forward to now, with newer technology and new reviews, the retina hack now, most of my retina surgeons probably don't even pick up a 20.00 D lens, they just look at the video or the picture and the 3D OCT and just basically say, "Okay, yeah, now I got to look at the periphery to fix it.” And then I have two surgeons that will actually look at me and say, "Karl, you shouldn't go in this eye. There's no reason to go in this eye." Unfortunately, we have to look at this individual every now and then, whoever that may be and say, "Look, let's try another avenue. Maybe you hadn't tried this contact lens, or maybe you haven't tried that form of visual aid or correction."

Sometimes, some of these people that can't go down those roads, you'll get them fit in a scleral lens because no one has ever tried a scleral or a SynergEyes lens in them. But, I think it goes back to just thinking outside the box. So about 3 years ago, maybe four now, and I haven't done a lot, but I've done enough to publish a series, and whenever I do a series, I usually have to have somewhere between 20 to 30 in my bag of tricks. And I've got to have at least a year or 2 of follow-up. So, I started looking at a lot of these pellucid marginal degeneration patients that had failed contact lenses. That's important because I think they see probably better in their contact lenses.

Gary: Right.

Karl: They came to me, and their glasses weren't working in their world or our world. And I said, "Okay, look, I now have these lenses that go up to T9, and maybe they won't eliminate your astigmatism, but if they can reduce it." We have done several of these pellucid marginal degeneration with a definable axis. And Jack Holladay will kind of go through that on the Pentacam: What's a definable access, and what's not a definable access, whether that's post-radial keratotomy when you're trying to fix your astigmatism or one of these pellucid patients.

I've had many pellucid patients that I've done now that are like these refractive patients. They're like, "Karl, I have never seen this good in anything, in my entire life." I remember one guy ended up -1.00 +3.00, -1.50 +3.00. He was essentially plano. I said, "Okay, let me get you glasses." And he goes, "I don't want glasses." And I said, "Well, I could maybe then get you contact lenses at this level." "I don't want contact lenses." I'm like, "Well, are you okay?" And he goes, "This is the best I've ever seen. I'm afraid you're going to mess me up if you give me glasses."

Sometimes getting close to perfect in some of these patients is even pretty spectacular. So, going back to this kid who went blind from Lebers, well, now he's not 20/20, but he's probably 20/80, maybe 20/100, and could ride a bike again. That's pretty fantastic medicine. I think with 3D-printed corneas, and some of the crazy stuff, we never thought we were going to stick a needle in the eye with this Avastin stuff and stop, or halt, or make people …

Gary: Reverse.

Karl: … in terms of age-related macular degeneration. I think if we just step back and think outside the box, and I always think to Australia. The term I use, or my patients tend to think it's funny, I say, "There's always going to be a tomorrow because it's already tomorrow in Australia." Because Australia is such a small community, their FDA can get things through the pipelines a lot quicker. So, they go down to T2 on their astigmatic lenses, and they go higher than our astigmatic lenses.

I think that at some point in time, we're going to get there to where we can expedite some of these things. Whether it's through a cognitive need or a concern need, I think that the FDA will kind of start thinking outside the box, because I operated on a lady that was at Quintiles, which they just changed their name, and I said, "Have you seen anything really crazy lately?" And she said, "The craziest thing I ever saw the FDA do recently was we were doing an immunotherapy therapy study versus chemotherapy in cancer."

She said, "I can't really go into the details of it, but he said the immunotherapy worked so well, the FDA called us up, "Stop the arm of chemotherapy because the patients were dying." All the immunotherapy patients were living, and said, "We're going to do this now. You still got to follow it for the 3-5 years, but everybody gets immunotherapy because it's so different."

Gary: That's awesome.

Karl: In the old days that would have never happened.

Gary: Well, maybe that's a sign of a sea change at the FDA, which we could only really all welcome. Well, Karl, thank you so much for giving us a little bit of the backstory, the rest of the story. And your points, your salient points about pushing the envelope in a responsible way, encouraging folks to try to make a profession even better than it already is, I can't thank you enough for being such an encouragement to me personally, but also to all the folks listening tonight. So, Karl, thank you so much. I really appreciate your time.

Karl: And like I said to you, I'm honored to be on here. Thanks for having me on.

Gary: Any time you want to come back, open invitation.

Karl: All right. Thank you, sir.

Gary: All right. Thanks. This has been Ophthalmology off the Grid with Dr. Gary Wörtz and Dr. Karl Stonecipher. Until next time, bye.

Gary: Many of the most extraordinary advances in ophthalmology have been fought against by those who wanted to maintain the status quo.

As we look ahead to the future, it's important to remember those in the past who had the courage to think outside the box. We can all benefit from being open to new ideas, because they might be the ones that change the game.

This has been Ophthalmology off the Grid. Thanks for listening.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.